Healthcare Provider Details

I. General information

NPI: 1164658795
Provider Name (Legal Business Name): KRISTIE LEIGH BRAGG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4741 HIGHWAY 153 STE A
EASLEY SC
29642-9161
US

IV. Provider business mailing address

4741 HIGHWAY 153 STE A
EASLEY SC
29642-9161
US

V. Phone/Fax

Practice location:
  • Phone: 864-661-5278
  • Fax: 864-408-8369
Mailing address:
  • Phone: 864-661-5278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL31778
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier317785
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: